Plymouth, MI · Wayne County
Insurance Claim/Incident Form
Plymouth residents and others reporting an incident or potential claim use this form to provide information for review by the city’s insurance company.
What this form is
Use this form to report an incident or submit a potential insurance claim to the City of Plymouth. It asks for incident dates, contact and insurance details, a description of the incident and loss, witnesses, and information about damaged items. Include supporting documentation or claim information; the document also includes legislation to review for claims related to a sewer backup.
Who needs it
Anyone reporting an incident or submitting a potential claim to the City of Plymouth should complete the form and include any supporting claim information.
How to submit it
Return the completed form and supporting documentation to the City of Plymouth Clerk’s Office, 201 S. Main St., Plymouth, MI 48170, or email [email protected].
About notarization
This form is signed and dated without a notary; the document does not identify any notarized or sworn attachment, so the signer just signs and dates it.
How to submit this form
- 1
Download The Form
Download the City of Plymouth Insurance Claim/Incident Form.
- 2
Complete The Form
Provide the incident dates, contact and insurance details, claim and loss information, witnesses, and damaged-item details.
- 3
Gather Supporting Documents
Include any additional supporting documentation or claim information. For a sewer backup claim, review the legislation on pages 3–6.
- 4
Submit To The City
Return the form and supporting information to the City of Plymouth Clerk’s Office by mail or email.
Frequently asked questions
- What is the Plymouth Insurance Claim/Incident Form for?
- It lets you report an incident or submit a potential claim to the City of Plymouth. The city forwards the information to its insurance company for review and determination.
- What information does the form ask for?
- It asks for incident dates, contact and insurance information, a description of the incident and loss, witness details, and information about damaged items. Include supporting documentation or claim information.
- How do I submit the Insurance Claim/Incident Form?
- Return the completed form and supporting documentation to the City of Plymouth Clerk’s Office at 201 S. Main St., Plymouth, MI 48170, or email [email protected].
- Do I need a notary for the Insurance Claim/Incident Form?
- No. This document is signed and dated without a notary and does not identify a notarized or sworn attachment; the signer just signs and dates it.